Obesity Paradox in the Burn Patient

Abstract Despite the fact that obesity is a known risk factor for comorbidities and complications, there is evidence suggesting a survival advantage for patients classified by body mass index (BMI) as overweight or obese. Investigated in various clinical areas, this “Obesity Paradox” has yet to be explored in the burn patient population. We sought to clarify whether this paradigm exists in burn patients. Data collected on 519 adult patients admitted to an American Burn Association Verified Burn Center between 2009 and 2017 was utilized. Univariable and multivariable logistic regression were used to determine the association between in-hospital mortality and BMI classifications (underweight <18.5 kg/m2, normal 18.5 to 24.9 kg/m2, overweight 25–29.9 kg/m2, obesity class I 30 to 34.9 kg/m2, obesity class II 35 to 39.9 kg/m2, and extreme obesity >40 kg/m2). For every kg/m2 increase in BMI, the odds of death decreased, with an adjusted odds ratio of 0.856 (95% confidence interval [CI] 0.767 to 0.956). When adjusted for total BSA (TBSA), being obesity class I was associated with an adjusted odds ratio of mortality of 0.0166 (95% CI 0.000332 to 0.833). The adjusted odds ratio for mortality for underweight patients was 4.13 (95% CI 0.416 to 41.055). There was no statistically significant difference in odds of mortality between the normal and overweight BMI categories. In conclusion, the obesity paradox exists in burn care: further investigation is needed to elucidate what specific phenotypic aspects confer this benefit and how these can enhance the care of burn patients.

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Management of the Patient with Thermal Injuries

DeckerMed Surgery ◽

10.2310/surg.2142 ◽

2016 ◽

Author(s):

Michael J. Mosier ◽

Nicole S. Gibran

Keyword(s):

Carbon Monoxide ◽

Carbon Monoxide Poisoning ◽

Fluid Management ◽

Clinical Manifestations ◽

Injured Patient ◽

Inhalation Injury ◽

Burn Patients ◽

Burn Care ◽

Burn Resuscitation ◽

Burn Patient

Optimal care of the burn patient requires not only specialized equipment but also, more importantly, a team of dedicated surgeons, nurses, therapists, nutritionists, pharmacists, social workers, psychologists, and operating room staff. Burn care was one of the first specialties to adopt a multidisciplinary approach, and over the past 30 years, burn centers have decreased burn mortality by coordinating prehospital patient management, resuscitation methods, and surgical and critical care of patients with major burns. This review covers where to treat burn patients, fluid management, airway management, temperature regulation, airway control, nutrition, anemia, pain management, deep vein thrombosis prophylaxis, and putting it all together: an algorithmic approach to early care of the burn-injured patient. Figures show that the size of a burn can be estimated by means of the Rule of Nines, which assigns percentages of total body surface to the head, the extremities, and the front and back of the torso, the approach to the burn patient in the first 24 hours, and the approach to the burn patient during the second to fifth days after burn injury. Tables list American Burn Association criteria for burn injuries that warrant referral to a burn unit, criteria for outpatient management of burn patients, acute physiologic changes during burn resuscitation, acute biochemical and hematologic changes during burn resuscitation, measures of pulmonary function, mechanisms of pulmonary dysfunction and indications for mechanical ventilation, clinical manifestations of carbon monoxide poisoning, half-life of carbon monoxide–hemoglobin bonds with inhalation therapy, increased acute kidney injury in patients treated with hydroxocobalamin for suspected inhalation injury, clinical findings associated with specific inhaled products of combustion, bronchoscopic criteria used to grade inhalation injury, and formulas for estimating caloric needs in burn patients. This review contains 3 highly rendered figures, 12 tables, and 134 references

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588 Peripheral Nerve Blocks in Procedural Care for Burn Injuries Less Than 10% Total Burn Surface Area: A Retrospective Chart Review.

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.238 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S145-S146

Author(s):

Kimberly Maynell ◽

Khattiya Chharath ◽

Thanh Tran ◽

Loryn Taylor ◽

David J Smith

Keyword(s):

Pain Management ◽

Pain Intensity ◽

Hospital Discharge ◽

Burn Injuries ◽

Burn Patients ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Burn Care ◽

Analgesic Consumption ◽

Significant Difference

Abstract Introduction Pain control remains one of the major challenges in management of burn patients. Pain associated with procedural and post-procedural burn care such as excision and grafting, postoperative dressing changes, and postoperative physical therapies often requires patients to be on intravenous and oral analgesics leading to potential long-term dependence after hospital discharge. Peripheral nerve blocks (PNB) use for perioperative pain management in burn patients may present an alternative pain management modality to help decrease analgesic consumption and shorten length of stay following procedural care. Our hypothesis was tested by evaluating the outcomes from implementation of PNB with ultrasound guided catheter placement for burn procedural care in patients with ≤ 10% total burn surface area (TBSA) requiring excision and grafting. Methods After IRB approval, we retrospectively collected demographics, medical history, pain intensity (rated as “No Pain” [NRS=0], “Minor Pain” [NRS 1 to 3], “Moderate Pain” [NRS 4 to 6], “Severe Pain” [NRS 7 to 10]), postoperative analgesic consumption and time to hospital discharge of patients who underwent autografting procedures for burn injuries ≤ 10% TBSA from October 1, 2019 to December 31, 2019 (the start of our implementation of PNB for procedural burn care). Data was analyzed using chi square/Fisher exact test for categorical variables and t-test for continuous variables. Results Our preliminary data included 20 patients (10 patients had PNB) with average age of 53 years, 60% males and average TBSA of 4.8%. Patients in both PNB and non-PNB groups had unremarkable medical histories and scald and flame as mechanism of burns. There was no significant difference in TBSA (5.3% TBSA in PNB and 4.8% TBSA in non-PNB). Pain intensity before autografting procedure for both groups were reported as moderate to severe and managed with fentanyl, morphine, oxycodone, along with ibuprofen and acetaminophen. There was no significant difference in postoperative pain intensity and opioid consumptions; however, postoperative acetaminophen consumption was less in PNB group compared to non-PNB group (2762±3646 mg vs 3932±7511 mg, respectively), although not statistically significant. There was no significant difference between time from surgery to first physical therapy session; however, time to hospital discharge was shorter in PNB group compared to non-PNB group (5.7±1 days vs 10.5±9 days, respectively), although not statistically significant. Conclusions This evaluation shows a trend in reduction of inpatient postoperative analgesic consumption as well as time to hospital discharge with the use of PNB, although a bigger sample size is needed for further assessment.

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A Prospective Study on the Association between Oxidative Stress and Duration of Symptoms in Allergic Rhinitis

Journal of Personalized Medicine ◽

10.3390/jpm11121290 ◽

2021 ◽

Vol 11 (12) ◽

pp. 1290

Author(s):

Hyun Moon ◽

Changsun Sim ◽

Jiho Lee ◽

Inbo Oh ◽

Taehoon An ◽

...

Keyword(s):

Oxidative Stress ◽

Allergic Rhinitis ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Inflammatory Responses ◽

Nasal Congestion ◽

Total Antioxidant Status ◽

Symptom Duration ◽

Duration Of Symptoms ◽

Significant Difference

Oxidative stress has been known to play an important role in inflammatory responses of allergic rhinitis. We investigated the association between degree of oxidative stress and severity of allergic rhinitis. A total 226 allergic rhinitis students were classified by a history of allergic rhinitis into groups according to number and duration of symptoms within the previous year. The total antioxidant status (TAS) and total oxidant status (TOS) levels were compared among groups. Mean TAS level (14.03 ± 9.09 mmol/L) in the group with more than six months of symptoms had a tendency to be higher (p = 0.068) than that of the group with fewer than six months (12.33 ± 8.83 mmol/L). There was no statistically significant difference in mean TAS or TOS level with number of symptoms (nasal congestion, itching, sneezing and watery rhinorrhea). A multivariate logistic regression showed that the adjusted odds ratio of TAS was 1.655 and the adjusted odds ratio of TOS was 0.972 in more than a six-month duration group. The TAS level was significantly associated with a more than six-month symptom duration (p = 0.034). Our results suggest that antioxidant activity increased when allergic rhinitis became chronic and further research will be needed considering the disease severity.

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Management of the Patient with Thermal Injuries

10.2310/7ccsp.2142 ◽

2016 ◽

Author(s):

Michael J. Mosier ◽

Nicole S. Gibran

Keyword(s):

Carbon Monoxide ◽

Carbon Monoxide Poisoning ◽

Fluid Management ◽

Clinical Manifestations ◽

Injured Patient ◽

Inhalation Injury ◽

Burn Patients ◽

Burn Care ◽

Burn Resuscitation ◽

Burn Patient

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Creencias de contagio casual, estigma y discriminación relacionados al VIH, en adolescentes que asisten a colegios oficiales en áreas urbanas de Panamá [HIVrelated beliefs of casual contagion, stigma, and discrimination among adolescents who attend public schools in urban areas of Panama]

Revista Médica de Panamá - ISSN 2412-642X ◽

10.37980/im.journal.rmdp.2020x1525 ◽

2021 ◽

Vol 40 (03) ◽

Author(s):

Anet Murillo ◽

Amanda Gabster ◽

Elisa Mendoza ◽

Gonzalo Cabezas Talavero ◽

Juan Miguel Pascale

Keyword(s):

Public Schools ◽

Hiv Infection ◽

Urban Areas ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Multivariable Logistic Regression Analysis ◽

Cluster Sampling ◽

Cross Sectional ◽

Stigma And Discrimination ◽

Significant Difference

Objetivo: Describir la prevalencia y factores sociodemográficos relacionados con las creencias de contagio casual de VIH. Entender los factores que están asociados a estigmas y discriminación hacia compañeros que viven con el VIH en la población adolescente (14-19 años) en centros educativos de nivel media de áreas urbanas de Panamá. Método: Se realizó un estudio de corte transversal con muestreo de conglomerados de dos-etapas, con selección aleatoria en 4 regiones urbanas de Panamá (Panamá, San Miguelito, Colón y Panamá Oeste). Se incluyó estudiantes 14-19 años de centros educativos públicos de educación media entre los meses de junio y agosto de 2015-2018 (una región por año). Se utilizó de regresión logística multivariable con efectos aleatorios. Resultados: Del total de 2466 participantes, el 56.9% era de sexo femenino y el 43.1% de sexo masculino. No se encontró una diferencia significativa entre el sexo de los participantes y la creencia en contagio casual. Después de ajustar el modelo por edad de los participantes, se encontró evidencia de asociación entre participantes de sexo masculino y el estigma (adjusted Odds Ratio [AOR]=1.44, 95% Intervalo de Confianza [IC]:1.14-1.82) y la discriminación (AOR= 2.02 95%CI:1.40-3.07). Al ajustar por sexo y edad de los participantes, se encontró evidencia de asociación entre creencias de contagio casual y estigma reportado (AOR=2.0, IC95%: 1.4-2.9), como también entre estigma y discriminación reportado (AOR=2.2 CI 95%:1.5-3.2). Conclusiones: Los estudiantes entre los 14-19 años que asisten a centros educativos públicos de nivel Media, presentaron una alta prevalencia de creencia de contagio casual del VIH, estigma y discriminación. Abstract:Objective: To describe the prevalence and sociodemographic factors related to beliefs of casual HIV infection. Understand the factors that are associated with stigma and discrimination towards peers living with HIV in the adolescent population (14-19 years) in high school educational centers in urban areas of Panama. Method: A cross-sectional study was carried out with two-stage cluster sampling, using random selection in 4 urban regions of Panama (Panama, San Miguelito, Colón and Panamá Oeste). The study was carried out among 14-19-year-old participants of public schools of secondary education between the months of June and August 2015-2018 (one region per year). Random-effects multivariable logistic regression analysis was used. Results: Of the total of 2,466 participants, 56.9% were female and 43.1% male. No significant difference was found between the sex of the participants and the belief of casual contagion. However, after adjusting the model for the age of the participants, we found evidence of an association between stigma (adjusted Odds Ratio [AOR] = 1.44,95% Confidence Interval[CI]:1.14-1.82) and discrimination (AOR = 2.02 95% CI:1.40-3.07) in the male participants. After adjusting for the sex and age of the participants, evidence of association was found among those with beliefs of casual contagion and reported stigma (AOR = 2.0, 95%CI:1.4-2.9), as well as strong evidence of association between stigma and reported discrimination (AOR = 2.2 95% CI:1.5-3.2). Conclusions: Students between the ages of 14-19 years who attend public schools of medium level, presented a high prevalence of belief of casual HIV infection, stigma and discrimination.

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Significance of lactate clearance in septic shock patients with high bilirubin levels.

10.21203/rs.3.rs-54817/v1 ◽

2020 ◽

Author(s):

Nozomi Takahashi ◽

Taka-aki Nakada ◽

Keith Walley ◽

James Russell

Keyword(s):

Septic Shock ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Hepatic Dysfunction ◽

Base Excess ◽

Total Bilirubin ◽

Validation Cohort ◽

Lactate Clearance ◽

Derivation Cohort ◽

Significant Difference

Abstract Background Although lactate clearance is affected by hepatic function, it is unclear whether the hepatic dysfunction is associated with lactate clearance as a prognostic marker of clinical outcomes in septic shock. We aimed to evaluate association between the lactate clearance and mortality divided by hepatic dysfunction based on total bilirubin level using two cohort of septic shock patients. Methods Lactate clearance, delta base excess and delta anion gap in 24 hours from septic shock onset were analyzed using two cohorts of septic shock patients (derivation cohort, n = 230; validation cohort, n = 396) categorized into two groups by total bilirubin levels (TBIL) < 2 mg/dL and ≥ 2 mg/dL on day 1. The primary analysis was association between lactate clearance and 28-day mortality by total bilirubin category. Results In derivation cohort, lactate clearance was lower in non-survivors compared to survivors in the patients with TBIL ≥ 2 mg/dL (P = 0.0035), while there was a no significant difference in those with TBIL < 2 mg/dL. There were no significant differences in delta base excess and delta anion gap between non-survivors and survivors both in the patients with TBIL ≥ 2 mg/dL and < 2 mg/dL. In the multivariate logistic regression analysis, increased lactate clearance was significantly associated with decreased 28-day mortality in TBIL ≥ 2 mg/d group (10% lactate clearance, adjusted odds ratio 0.88, 95%CI; 0.80–0.97, P = 0.0075), whereas there was no significant association in TBIL < 2 mg/d group. We next tested for lactate clearance in TBIL ≥ 2 mg/dL using the validation cohort; lactate clearance was lower in non-survivors compared to survivors in the TBIL ≥ 2 mg/dL group (P = 0.0006), while no significant difference was observed in TBIL < 2 mg/dL. Increased lactate clearance was significantly associated with decreased 28-day mortality in the TBIL ≥ 2 mg/dL group (10% lactate clearance, adjusted odds ratio 0.89, 95%CI; 0.83–0.96, P = 0.0038); while no significant difference was observed in TBIL < 2 mg/dL in the validation cohort. Conclusions Patients with increased lactate clearance had decreased 28-day mortality when patients had hepatic dysfunction (TBIL ≥ 2 mg/dL) in septic shock.

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Comparison of Post-Tonsillectomy Hemorrhage between Monopolar and Plasma Blade Techniques

Journal of Clinical Medicine ◽

10.3390/jcm10102051 ◽

2021 ◽

Vol 10 (10) ◽

pp. 2051

Author(s):

Andy Wei-Ge Chen ◽

Mu-Kuan Chen

Keyword(s):

Odds Ratio ◽

Adjusted Odds Ratio ◽

Thermal Damage ◽

Postoperative Bleeding ◽

Postoperative Hemorrhage ◽

Bleeding Events ◽

Significant Difference

The plasma blade is an innovative device that was recently introduced for performing tonsillectomy. While one of the benefits of the plasma blade is limited thermal damage, the effects of plasma blades on postoperative hemorrhage have not been thoroughly investigated. Patients who underwent tonsillectomy in our institution between January 2013 and September 2018 were retrospectively enrolled in the study. A total of 1214 patients were enrolled in the study, with 759 participants who underwent monopolar tonsillectomy and 455 participants who underwent plasma blade tonsillectomy. In total, 14 bleeding events occurred in the monopolar group, and 10 events occurred in the plasma blade group. The odds ratio for postoperative bleeding in the plasma blade group was 1.20 (95% CI 0.52 to 2.72). After adjusting for potential confounders, the adjusted odds ratio was 1.34 (95% CI 0.58 to 3.07). In conclusion, there is no significant difference in post-tonsillectomy hemorrhage rates between the traditional monopolar technique and plasma blade technique. Plasma blade tonsillectomy can be considered as safe as traditional monopolar tonsillectomy.

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Nurse Staffing, the Clinical Work Environment, and Burn Patient Mortality

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa061 ◽

2020 ◽

Vol 41 (4) ◽

pp. 796-802 ◽

Cited By ~ 1

Author(s):

Amanda P Bettencourt ◽

Matthew D McHugh ◽

Douglas M Sloane ◽

Linda H Aiken

Keyword(s):

Work Environment ◽

Nurse Staffing ◽

Additional Patient ◽

Future Research ◽

Burn Patients ◽

Thermal Burn ◽

Cross Sectional ◽

Burn Care ◽

Hospital Nursing ◽

Burn Patient

Abstract The complexity of modern burn care requires an integrated team of specialty providers working together to achieve the best possible outcome for each burn survivor. Nurses are central to many aspects of a burn survivor’s care, including physiologic monitoring, fluid resuscitation, pain management, infection prevention, complex wound care, and rehabilitation. Research suggests that in general, hospital nursing resources, defined as nurse staffing and the quality of the work environment, relate to patient mortality. Still, the relationship between those resources and burn mortality has not been previously examined. This study used a multivariable risk-adjusted regression model and a linked, cross-sectional claims database of more than 14,000 adults (≥18 years) thermal burn patients admitted to 653 hospitals to evaluate these relationships. Hospital nursing resources were independently reported by more than 29,000 bedside nurses working in the study hospitals. In the high burn patient-volume hospitals (≥100/y) that care for the most severe burn injuries, each additional patient added to a nurse’s workload is associated with 30% higher odds of mortality (P < .05, 95% CI: 1.02–1.94), and improving the work environment is associated with 28% lower odds of death (P < .05, 95% CI: 0.07–0.99). Nursing resources are vital in the care of burn patients and are a critical, yet previously omitted, variable in the evaluation of burn outcomes. Attention to nurse staffing and improvement to the nurse work environment is warranted to promote optimal recovery for burn survivors. Given the influence of nursing on mortality, future research evaluating burn patient outcomes should account for nursing resources.

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Periprocedural Intravenous Heparin During Endovascular Treatment for Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.025329 ◽

2019 ◽

Vol 50 (8) ◽

pp. 2147-2155 ◽

Cited By ~ 3

Author(s):

Rob A. van de Graaf ◽

Vicky Chalos ◽

Adriaan C.G.M. van Es ◽

Bart J. Emmer ◽

Geert J. Lycklama à Nijeholt ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Functional Outcome ◽

Intracranial Hemorrhage ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Common Odds Ratio ◽

Intravenous Heparin ◽

Significant Difference ◽

Symptomatic Intracranial Hemorrhage

Background and Purpose— Intravenous administration of heparin during endovascular treatment for ischemic stroke may improve outcomes. However, risks and benefits of this adjunctive therapy remain uncertain. We aimed to evaluate periprocedural intravenous heparin use in Dutch stroke intervention centers and to assess its efficacy and safety. Methods— Patients registered between March 2014 and June 2016 in the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke), including all patients treated with endovascular treatment in the Netherlands, were analyzed. The primary outcome was functional outcome (modified Rankin Scale) at 90 days. Secondary outcomes were successful recanalization (extended Thrombolysis in Cerebral Infarction ≥2B), symptomatic intracranial hemorrhage, and mortality at 90 days. We used multilevel regression analysis to evaluate the association of periprocedural intravenous heparin on outcomes, adjusted for center effects and prognostic factors. To account for possible unobserved confounding by indication, we analyzed the effect of center preference to administer intravenous heparin, defined as percentage of patients treated with intravenous heparin in a center, on functional outcome. Results— One thousand four hundred eighty-eight patients from 16 centers were analyzed, of whom 398 (27%) received intravenous heparin (median dose 5000 international units). There was substantial between-center variability in the proportion of patients treated with intravenous heparin (range, 0%–94%). There was no significant difference in functional outcome between patients treated with intravenous heparin and those without (adjusted common odds ratio, 1.17; 95% CI, 0.87–1.56), successful recanalization (adjusted odds ratio, 1.24; 95% CI, 0.89–1.71), symptomatic intracranial hemorrhage (adjusted odds ratio, 1.13; 95% CI, 0.65–1.99), or mortality (adjusted odds ratio, 0.95; 95% CI, 0.66–1.38). Analysis at center level showed that functional outcomes were better in centers with higher percentages of heparin administration (adjusted common odds ratio, 1.07 per 10% more heparin, 95% CI, 1.01–1.13). Conclusions— Substantial between-center variability exists in periprocedural intravenous heparin use during endovascular treatment, but the treatment is safe. Centers using heparin more often had better outcomes. A randomized trial is needed to further study these effects.

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Association between P2RY12 Gene Polymorphisms and IVIG Resistance in Kawasaki Patients

Cardiovascular Therapeutics ◽

10.1155/2020/3568608 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6

Author(s):

Zhouping Wang ◽

Yufen Xu ◽

Huazhong Zhou ◽

Yanfei Wang ◽

Wei Li ◽

...

Keyword(s):

Confidence Interval ◽

Odds Ratio ◽

Gene Polymorphisms ◽

Adjusted Odds Ratio ◽

Purinergic Receptor ◽

Age And Gender ◽

Ivig Resistance ◽

Significant Difference ◽

And Gender ◽

The Relationship

Children with Kawasaki disease (KD) resistant to intravenous immunoglobulin (IVIG) have a higher incidence of coronary artery lesions (CAL). Despite the association between Purinergic receptor P2Y12 (P2RY12) polymorphism, KD genetic susceptibility, and CAL complications being proved, few studies have assessed the relationship between P2RY12 polymorphisms and IVIG resistance in patients with KD. We recruited 148 KD patients with IVIG resistance and 611 with IVIG sensitivity and selected five P2RY12 polymorphisms: rs9859538, rs1491974, rs7637803, rs6809699, and rs2046934. A significant difference in the genotype distributions between patients was only observed for the rs6809699 A > C polymorphism (AC vs. AA: adjusted odds ratio (OR) = 0.48, 95% confidence interval (CI) = 0.27–0.84, P=0.011; AC/CC vs. AA: adjusted OR = 0.47, 95% CI = 0.27–0.83, P=0.0084). After adjusting for age and gender, the carriers of the rs6809699 C allele had OR of 0.44 to 0.49 for IVIG sensitivity (AC vs. AA: adjusted OR = 0.48, 95% confidence interval (CI) = 0.27–0.84, P=0.011; AC/CC vs. AA: adjusted OR = 0.47, 95% CI = 0.27–0.83, P=0.0084) compared to the carriers of a rs6809699 AA genotype, suggesting the protective effect of this SNP against IVIG resistance. Moreover, individuals with all five protective polymorphisms experienced a significantly decreased IVIG resistance compared to that of individuals with up to three protective polymorphisms (adjusted OR = 0.27, 95% CI = 0.13–0.57, P=0.0006). Our results suggest that the P2RY12 rs6809699 polymorphism could be used as a biomarker to predict IVIG resistance in KD patients.

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